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CARE PATHWAY AND MODEL FOR
COMMUNITY FORENSIC
TEAMS IN
N. IRELAND
OCTOBER 2011
Page 2 of 28
Acknowledgements
The authors Hugo Kelly (SHSCT), Terry Mc Cabe (NHSCT), Dr Paul Devine
(BHSCT) & Brian Simpson (WHSCT) wish to acknowledge the significant
contribution and support received from all members of the Bamford Forensic
Services sub-group. The completion of this document was achieved through
the collaboration of the various agencies involved in the management and
care of Mentally Disordered Offenders.
Membership of the Bamford Forensic Sub Group:
• Molly Kane, Public Health Agency (Forensic, Joint Chair)
• Hugo Kelly, SHSCT (Forensic, Joint Chair)
• Dr Ian McMaster, DHSSPS (Low Secure Lead)
• Jackie Scott, BHSCT
• Dr Ian Bownes, WHSCT
• Terry McCabe, NHSCT
• Paul McMonagle, BHSCT (Patient Advocate,
• Paul Devine, BHSCT (Shannon Clinic)
• Noel McDonald, BHSCT
• Jackie Elliott, BHSCT (Shannon Clinic)
• Barry Mills, BHSCT (Learning Disability)
• Calum McDonald, HM Prison & Young Offender’s Centre
• Helen Kennedy, HSCB (Prison)
• Adrian East, Shannon Clinic
• Jane Reynolds, NHSCT (AHP)
• Pat Conway, NIACRO
• Geraldine O’Hare, Probation Board for NI
• Maura Harper, CAUSE
• Mary Donaghy, HSCB (Social Work)
• Yvonne McWhirter, WHSCT
• Brian Simpson, WHSCT
Page 3 of 28
Contents:
Section 1: Introduction and background. 4
Section 2: Current service provision. 6
Section 3: Definition of Client group. 10
Section 4: Referral Process 12
Section 5: Risk Assessment/Management and Therapeutic Interventions: 17
Section 6: Outcomes/Evaluation Measures. 18
Glossary 19
Appendices 20
Page 4 of 28
SECTION 1: INTRODUCTION & BACKGROUND
Introduction
The main purpose of this paper is to provide a composite regional care
pathway for community forensic mental health and learning disability services.
It outlines the links needed with probation, prison and police services as an
integral element to provide streamlined access to community forensic
services. In addition this paper provides an overview of current arrangements
and processes within forensic mental health and learning disability services in
place across Northern Ireland.
The paper makes reference to Community Forensic Teams (CFT’s) as
defined in Bamford 2006, for ease of reading. CFT’s covers both Community
Forensic Mental Health Teams (CFMHT) and Community Forensic Learning
Disability Teams (CFLDT), with each service, where available, working within
their own specialisms. In Trusts where there is no CFLDT established, the
CFMHT will provide advice on such issues as offending behaviour and risk
management where appropriate. It is recognised that this arrangement is not
endorsed in every Trust area; however a Forensic Learning Disability proposal
is being taken forward to address this deficit.
Background
The Public Health Agency and Health & Social Care Board established the
Mental Health and Learning Disability Taskforce in 2010 to take forward the
implementation of the Bamford Action Plan 2009-11 which was the
DHSSPSNI response to the Bamford Review of Mental Health and Learning
Disability Services (2007).
The Mental Health & Learning Disability Commissioning Team is responsible
for planning and commissioning services through the Board and Agency, and
for supporting and assisting the overall constituent elements of the service
team structure i.e. Project Board/Commissioning Board and the range of sub
groups. Membership of the sub groups includes a wide range of stakeholders,
including the voluntary and community sector, service users and carers
(appendix 1).
The Bamford Specialist High Support Services Sub-Group forms one of the
work streams that are responsible for taking forward specific work packages
within a number of workstreams, of which the Bamford Forensic Sub Group is
one. Members of the Bamford Forensic Sub Group identified the need to
Page 5 of 28
review the community forensic services care pathway document that was
produced in 2006 to more accurately reflect and inform on current community
forensic health care provision.
Definition of a Care Pathway
An integrated care pathway is a multi-disciplinary outline of anticipated care,
placed in an appropriate timeframe to help a patient with a specific condition
or set of symptoms move progressively through a clinical experience to
positive outcomes (www.evidence-based-medicine.co.uk, 2001)
The purpose of a forensic health care pathway is to ensure that service users
are receiving a quality service that is accessible and appropriate to their
needs.
The formation of a care pathway allows for better monitoring and streamlining
of the care process, this is of particular relevance where there are a range of
professionals/agencies involved in the management of the client. This in turn
helps to ensure a high degree of efficiency and consistently delivered care
regionally, thus reducing unnecessary variations in treatment and outcomes.
The care pathway also supports the development of care partnerships, a vital
component of interagency collaborative working, whilst at the same time
empowering clients and their carers to participate and contribute to their
specific care needs.
The development and implementation of a care pathway informs outcome
measures and is an integral part of both Quality and Modernisation agendas
across health communities. “They are key to reducing variations in
healthcare... are crucial to ensuring the delivery of care that is safe, effective,
patient centred, timely, efficient and equitable.” (Davis 2004).
Strategic Context
There are a number of significant strategic drivers that underpin the need for a
co-ordinated and streamlined care pathway for community forensic mental
health and learning disability services. Further detail can be found at Appendix
2.
Page 6 of 28
SECTION 2: CURRENT SERVICE PROVISION
Mental Health
High Secure Services
Currently in Northern Ireland there is no provision for high secure services;
this service is provided by the State Hospital Carstairs in Scotland (male) and
Rampton in England (female). In exceptional circumstances male patients
may also be located in any of the 3 High Secure Hospitals in England.
Medium Secure Services
Shannon Clinic, on the Knockbracken site in Belfast, provides regional
medium secure inpatient services. The Unit is made up of 34 beds spread
across 3 wards:
• Ward 1: Admission/Assessment and Intensive Care
• Ward 2: Continuing Care Services
• Ward 3: Rehabilitation
Ward two has five beds that can be made available for female patients,
although this is not a dedicated provision. The Unit is supported by the four
Community Forensic Mental Health Teams across the region who each
deliver services to their respective Trust population.
Low Secure Services
There is currently no dedicated low secure provision for forensic mental health
patients in Northern Ireland.
Community Forensic Mental Health Services / Teams
There is a Community Forensic Mental Health Team (CFMHT) in each of the
Trusts across the region, with the exception of the South Eastern Trust which
is covered by the Belfast Trust’s CFMHT.
Learning Disability
High secure Services
Within Northern Ireland there is currently no high secure service provision for
forensic learning disability clients. Currently forensic learning disability
services for male clients are accessed through The State Hospital, Scotland,
with services for female clients again being provided by Rampton Hospital.
Page 7 of 28
Medium Secure
There is currently no dedicated medium secure provision for this client group,
causing individuals to remain in high secure settings for longer than necessary
or to be inappropriately placed in a low secure setting.
Low Secure
Learning Disability in-patient forensic services are provided by the Sixmile
Low Secure Unit on the Muckamore site. This unit caters solely for male
clients and there is currently no low secure provision for females, although
they may be admitted to Cranfield Unit, Muckamore. The Sixmile Unit is
comprised of two elements, a 4 bed assessment unit and a 15 bed treatment
unit. The Unit is predominantly supported by generic learning disability
community teams which include senior social work practitioners who act as
designated risk managers as defined by PPANI, and where available
Community Forensic Learning Disability practitioners and Community
Forensic Learning Disability psychologists.
Community Forensic Learning Disability Services / Teams
Three out of the five Trusts, Northern, Southern and Belfast, currently provide
dedicated community forensic services for their respective learning disability
populations. These services are delivered via two service models. The
Northern Trust CFLDS is integrated within the CFMHS infrastructure working
to the same protocols and operational policies, and availing of the same
training and supervision as their forensic mental health colleagues. The
alternative existing approach is a stand alone model, as is the case in the
Southern Trust (the senior Forensic Practitioners in the mental health team
however have dedicated time devoted to the Community Learning Disability
Team to promote an integrated model) and more recently the Belfast Trust. In
January 2011, the Belfast Trust commissioned a community forensic learning
disability post (Forensic Psychologist) with the intention of developing a
comprehensive service. Current arrangements mitigate against delivery of
services at level 4 although clients requiring complex and specialist
assessments and interventions can be facilitated.
For both CFMHS and CFLDS the underpinning rationale for service delivery is
the need to support the smooth transition from secure provision towards
community integration. In addition their role is to support adult mental health
and learning disability services in the risk assessment and safe management
of those clients who meet the defined criteria as laid out in Section 3.
Collaborative working with the Criminal Justice Service is paramount in the
contribution to the assessment, treatment and management of Mentally
Disordered Offenders whilst promoting recovery and being mindful of public
safety (appendices 6 & 7).
Page 8 of 28
This care pathway recommends that community forensic teams should work
within the four level model outlined below:
Level 1 - A specialist consultation, education and training role which may
include, for example, CFT attendance at case reviews to offer advice and
support to generic teams, and a service co-ordination role or liaison between
health and criminal justice. This will also include initial assessments following
referral to determine immediate needs and decrease response time to
referring agent.
Level 2 - An in-depth assessment (which may include a standardised risk
assessment and management plan) prepared by the CFT with the referring
team retaining responsibility.
Level 3 - An agreed period of shared responsibility for any or all of a variety of
reasons including to assess risk; to evaluate the interplay/operation of known
risk factors; to offer a specialist piece of therapeutic work; and to assess the
efficacy of risk reducing strategies.
Level 4 – CFT taking full responsibility for the duration of need with referral
back to the appropriate services when deemed appropriate. This will be
particularly evident for clients being discharged from secure environments into
the community (MSU, NIPS).
It would be assumed that the majority of the CFT’s work would be at level 1
with only a small minority at level 4. (Bamford 2006).
Forensic mental health and learning disability services aim to uphold the
underlying philosophy of recovery focused services in line with the
Departmental Guidelines on Promoting Quality Care (2010) and the service
development standards as defined in Bamford (2006). The Bamford High
Support Services Sub Group supports the implementation of the Bamford
standards in principle considering the current resource limitations.
Team structure and Multi-disciplinary working
The multi-disciplinary team (MDT) across the scope of forensic services
consists of a range of professionals including Forensic Psychiatry,
Forensic/Clinical Psychology, Nursing, Social Work and Occupational
Therapy. These professionals work in support of each other to ensure best
outcomes for the clients, being mindful of their own accountability and the way
in which they practice.
The MDT approach to care delivery is best evidenced and supported through
the implementation of the Department of Health’s New Ways of Working for
Page 9 of 28
Everyone, (NWW) (2007). This document gives clear indicators of effective
multi-disciplinary team working, and should be evidenced in the delivery of
forensic healthcare regardless of the setting (appendix 3).
In order to ensure a regionally consistent evidence based approach to care
delivery, training needs analysis and subsequent commissioning should be
undertaken at a regional level on an annual basis. This will ensure that all
forensic practitioners have equal access to training, thus minimising the
potential for inequalities in service delivery.
Quality and safety:
Key priorities for CFTs are to ensure a focus on safety and continuous
improvement in the quality of services. CFTs will foster a culture of openness
and learning where staff will feel supported and concerns about safety and
care can be openly discussed. Training, personal development and
supervision for all staff will be the cornerstone of the strategy to deliver safe,
high quality care.
CFTs will provide care and treatment that is evidence based. Regular audit
and evaluation processes will enable CFTs to assess their performance using
a range of audit measures to evaluate clinical outcomes, service level
outcomes, patient reported outcomes and patient reported experiences.
As national standards for community forensic services are developed it is
anticipated that CFTs will aspire to benchmark their service against these
standards.
Where disputes arise between agencies relating to their respective roles and
responsibilities resolution should be sought through local senior management
structures in the first instance.
Page 10 of 28
SECTION 3: DEFINITION OF CLIENT GROUP
Patients suitable for referral to a CFT are usually (but not exclusively)
between the ages of eighteen and sixty-five, currently suffering from a mental
disorder (as defined in the 1986 Northern Ireland Mental Health Order) and
who require a forensic service on the basis of either (i) risk, (ii) specialist need
or (iii) continuity of care. The service will also provide advice/guidance to
referring agents where the level of risk is not clearly defined but there are
ongoing concerns. The categories are further explored below:
Risk: The patients will have behaviour that may bring them into contact with
the Criminal Justice system and are a cause for concern, either because of
the seriousness of their offending or their significant risk (that which is
sufficiently serious to warrant a response) of causing serious harm to others.
Serious offending would include serious violence (such as murder,
manslaughter, attempted murder, threats to kill or malicious wounding with
intent, arson, kidnapping and any offence against a vulnerable adult) or a
history of serious sexual offence against an adult or any sexual offence
against a child.
Serious harm is defined in the Public Protection Arrangements for Northern
Ireland Manual of Practice as “Harm (physical or psychological) which is life
threatening and/or traumatic and from which recovery is usually difficult or
incomplete”.
Specialist need: The patients should have forensic needs, which cannot be
met by other available Mental Health or Learning Disability Services.
For example as personality disorder services continue to develop at primary,
secondary and tertiary levels, the CFT, in line with NICE guidance, may offer
for people with complex needs and challenging behaviours a structured
assessment of personality functioning, and where appropriate specialist risk
assessment to inform the delivery of treatment interventions (see Section 5).
Continuity of care: It is expected that all conditionally discharged restricted
patients and those patients who have been discharged from high or medium
secure mental health services will require advice to be sought from forensic
services regarding the prospective management of the case.
Exit criteria conversely should apply as risk diminishes or is reasonably
reduced/managed to an acceptable level. This will be after an agreed period
Page 11 of 28
of observed stability and may coincide for example with the absolute
discharge of a restriction order or the reduction in risk category by Public
Protection Arrangements for Northern Ireland to category 1.
Page 12 of 28
SECTION 4: REFERRAL PROCESS
Community Forensic Team’s (CFT’s) ideally function as a tertiary level service
within the spectrum of both mental health and learning disability services. It is
therefore important to ensure that the referral process is compatible with the
current structures already in place across services.
Mental health services have /are in the process of implementing the regionally
agreed ‘stepped care model’. The implementation of this model follows the
strategic vision of a system that ensures the most effective, yet least resource
intensive, treatment is delivered to the patient (CSIP 2006). In essence, this
means, having the right service in the right place, at the right time delivered by
the right person.
A number of principles underpin the delivery of an effective and efficient
stepped care model of service delivery, see appendix 4 for further detail.
Appendix 5 sets out the diagrammatic version of the Care Pathway.
Referrals from generic mental health and learning disability services:
The aim of CFT’s is to provide an inclusive and equitable service that is
underpinned by the multi-disciplinary team making decisions which are based
on client need and the teams’ expertise to address those needs.
Each service will have an operational policy that clearly outlines the systems
and processes in operation to facilitate robust governance in the management
of referrals into the service. These governance arrangements must take
cognisance of the Health and Social Care Boards (HSCB) 2010 Mental Health
Services Integrated Elective Access Protocol Addendum (IEAP). The key
principles underpinning the referral process are:
• All referrals should be on the prescribed proforma i.e. a Community
Services Referral Form including an up to date Comprehensive Risk
Assessment (in line with Promoting Quality Care guidelines) and a
case summary review letter from the referring agent (Team Leader /
Consultant).
• All referrals are made to the Multi-disciplinary team and not
individuals within the team.
• Referrals will be accepted from both community based services and
inpatient services.
Page 13 of 28
• On receipt all referrals are screened by a member of the forensic
team to determine urgency, this should be done by the end of the
next working day.
• All referrals are discussed at the Multi-disciplinary forensic team
meeting, no more than seven working days from receipt, where
consensus is reached on the appropriateness of the referral.
• If the referral is deemed appropriate, the referral will be allocated to a
team member at that meeting.
• The Multi-disciplinary forensic team will communicate the outcome of
their discussions to the referring agent and the GP as soon as
practical following the close of the meeting but no later than three
working days.
• Patients who require interventions will be seen within 15 working days
from the date of acceptance by the team.
• For cases accepted at level 2 the appointed practitioner will contact
the referral agent to update on initial findings within fifteen working
days.
• The decision to intervene at level 3 & 4 will be decided by CFS
following consultation with the referral agent.
Forensic Patients moving across Trust Boundaries:
• Where a patient, who is known to CFT, moves to/plans to move to
another Trust area, it is the responsibility of the originating Trust to
convene a transfer of care meeting with the receiving Trust within 15
working days prior to relocation.
• If the move is unplanned, the originating Trust should coordinate a
transfer of care meeting with the receiving Trust within 7 working days
of move becoming known.
• The originating Trust will provide a minimum data set which will include
the case summary report, referral form and up to date comprehensive
risk assessment in line with Promoting Quality Care Guidelines, as part
of the transfer process.
• The responsibility for care resides with the Trust coordinating the
transfer until such time as the transfer is complete.
Forensic Patients released from prison to non-originating Trust locality:
• When released from prison a forensic patient may through choice
relocate to another Trust catchment area so that their care will be the
responsibility of the receiving Trust. Where these arrangements are
temporary (e.g. as part of Bail conditions) care will be temporarily
coordinated by the receiving Trust CFT, with support and input from the
originating Trusts CFT in line with Promoting Quality Care Guidelines.
Page 14 of 28
• The Prison Healthcare Discharge Liaison Team (DLT) will coordinate
with the originating Trust to ensure that Promoting Quality Care
Guidelines are implemented in relation to this patient group.
Patients returning to N. Ireland following a period of care and treatment
in the UK (Extra Contractual Referrals).
• Where forensic health services are involved in the repatriation of ECR
patients, the role of the Care Coordinator remains with the originating
Trust, regardless of where the patient is relocating to.
• This duty of care remains in force for a period not exceeding 6 months
by which time the duty of care rests with the receiving Trust.
• The originating Trust will ensure that the Promoting Quality Care
Guidelines are adhered to through the transfer process, facilitating and
coordinating an appropriate number of meetings to ensure smooth
transition of care.
• The originating Trust care co-ordinator will liaise with the receiving
Trust to identify appropriate services prior to repatriation and will work
collaboratively during the six month transition period.
Interface with Secure Units (Shannon Clinic/Sixmile Unit):
• The CFT will allocate a named professional to each patient from their
Trust residing in these secure units.
• The named professional will attend secure unit review meetings
regularly and report back to the CFT multi-disciplinary team.
• The named professional will endeavour to establish a therapeutic
relationship with the patient prior to discharge.
• The named professional will actively participate in the discharge
process for patients who will be returning to their respective Trust area.
Referrals from the Criminal Justice Services:
All referrals into forensic services are predicated by the need to adhere to
each respective Trust’s single point of access and the referral criteria as
defined earlier in this document. To facilitate this process the CFT will act as
a conduit/facilitator to ensure that the referred client, if required, has access/is
known to core services.
Probation Board NI:
• Community forensic health services will accept referrals for initial
assessment from Probation Services via the Probation Psychology
Dept.
Page 15 of 28
• Community Forensic Learning Disability Teams can only accept
referrals via tier two services at this time i.e. PBNI need to refer to
generic LD services in the first instance.
• Should the client require input from secondary mental health services
and is not currently known/open to them the CFT will work in
collaboration with the referring agent to ensure safe seamless
engagement.
• All referrals from PBNI will be discussed at pre-arranged multi-
agency/multi-disciplinary meetings. These discussions will be informed
by the appropriate documentation to include referral form and a written
risk formulation report.
• If at initial assessment it is evident that CFT or core mental
health/learning disability services have no input to deliver, the case will
be returned to the referring agent.
• A client who is currently open to CFT and who has a Probation Order in
place will be managed via a joint agreement between the respective
agencies, being mindful of PBNI statutory functions and
responsibilities.
• The PBNI psychologist should, following agreement, attend the CFT
team meetings on a regular basis (approx 8-12 weekly) to discuss
currently opened cases and where appropriate new cases for
consideration by the team. This timeline is by nature flexible and will
be dictated by level of need and urgency.
• Reaching consensus/agreement on case management responsibilities
will be facilitated through a multi-agency meeting coordinated by the
CFT, being mindful of the PBNI statutory function and responsibilities.
Prison Services: (pathway out)
Forensic Needs:
• The CFT will work closely with the Discharge Liaison Team (DLT) to
facilitate the smooth transition from prison into the community of those
prisoners deemed to be suffering from a mental disorder who fall under
the remit of “Promoting Quality Care”. This is because of the risk to
others, with identified forensic needs and in need of on-going
secondary level mental health/learning disability care.
• Prior to discharge the DLT will make contact with the relevant CFT to
coordinate a pre-discharge meeting to facilitate the transfer of care
from prison health care to community services for those individuals who
fall under the PQC Guidelines.
• All such meetings should be compliant with the PQC Guidelines and
referrals to CFT should be on the prescribed proforma.
Page 16 of 28
Non Forensic Needs:
• Where the prisoner requires secondary mental health/learning disability
services CFS will liaise with the appropriate Community Team to
facilitate discharge from the prison to the appropriate service.
• This transition process will be informed by the client’s response to
treatment and evidence of ongoing manageable levels of risk.
Prison Services: (pathway in)
• The CFT will inform the DLT when a forensic patient (managed at level
3/4) is committed to prison. They will provide a minimum data set
comprising of case summary report in line with PQC Guidance and a
up to date comprehensive risk assessment within two working days.
• The CFT will, if required, act as a contact point to support effective
communication between the DLT and core mental health/learning
disability services. The DLT will link with appropriate NIPS mental
health services.
Police Service of N. Ireland:
The development of a composite regional care pathway, and supporting
protocols, is required to manage the day to day interface with the PSNI in
particular for the effective and timely management of vulnerable adults and
offenders with mental health and learning disability needs who fall outside
of the CFT criteria. CFT’s are primarily concerned with those patients
subject to PPANI, and as such the PSNI do not have a direct referral route
into CFT’s. This does not preclude the PSNI referring into each Trusts
respective single point of access.
• Where a mental health/learning disability patient is managed though
PPANI the CFT may act as care providers where appropriate.
• The Trust representative in PPANI will liaise with the CFT where the
patient is open to mental health/learning disability services.
• There is an expectation that all mental health/learning disability
patients under PPANI should be allocated to a forensic practitioner.
This will be facilitated through regular communication between the
CFT and the respective Trust’s representative on the Local Area
Public Protection Panel.
Page 17 of 28
SECTION 5: Risk Assessment/Management & Therapeutic Interventions.
CFT’s provide care and treatment for individuals who have a major mental
disorder and demonstrate serious offending behaviours or present a
significant risk to others. The CFT offers assessment, consultation, care and
treatment, which is proportionate to the situation and underpinned by risk
assessment/management and treatment of offending behaviours. Where
deemed appropriate and to assist in the formulation of treatment needs,
psychological assessments are also undertaken, for example, personality
assessments (IPDE), Psychopathy Checklist (R) (PCLR) etc .
Interventions by the CFT are preceded by the timely, comprehensive and
professional completion of evidenced based assessments of risk. CFT’s use
a varying range of evidence based risk assessment tools for this purpose.
The completion of informed detailed risk assessments facilitates the
formulation of robust multi-disciplinary risk management strategies, which in
turn inform the therapeutic process whilst promoting public safety and
emphasising a strong recovery based ethos to service delivery.
Interventions are predominantly based on the cognitive behavioural model,
and delivered at both an individual and group level. Group interventions use a
Cognitive Behaviour Therapy (CBT) approach and include psychosocial and
life skills training such as Motivational Enhancement, Good Thinking Skills
and Anger Management. Depending on the assessed needs, group
interventions can be delivered on a one to one basis, if it is not appropriate for
the client to participate in group work, or as booster sessions following group
participation.
Although these groups predominantly target community clients, in-patients
can also attend following assessment. Alternatively the CFT may in-reach into
acute facilities to deliver one to one interventions.
Other treatment approaches include.
o Pharmacotherapy
o Use of positive behavioural management approaches
o Offence and offending type related work
o Sex offending related work
o Substance misuse work
o Medication concordance therapy
o Relapse prevention therapy
o Psychosocial interventions with families
o Developing contingency plans for crises and relapses.
Page 18 of 28
SECTION 6: Evaluation measures.
Having identified the objectives of CFS as outlined in appendix 6, CFS recognises the need to ensure robust systems and processes are in place against which the service delivery can be measured and held accountable. This is a key component in ensuring a safe and effective service given that CFS is delivered across a range of interfaces and agencies. CFS will by March 2013 developed a range of standards and performance indicators encompassing Lord Darzi's 2008 'High Quality Care for All' definition of quality. Lord Darzi’s review sets out a vision of high quality care, in which quality is defined as: clinically effective, personal and safe. The main themes of the standards will focus on:
• Primary focus on delivery of high quality care for patients
• Reducing variation in quality of care delivered
• Empowering patients to make their own choices
• Safe care - getting the basics right
• Preventative care, measures to improve health and well being
Page 19 of 28
Glossary
CFT Community Forensic Team
CFMHT Community Forensic Mental Health Team
CFLDT Community Forensic Learning Disability Team
CFMHS Community Forensic Mental Health Services
CFLDS Community Forensic Learning Disability Services
PPANI Public Protection Arrangements Northern Ireland
BHSCT Belfast Health & Social Care Trust
NHSCT Northern Health & Social Care Trust
SHSCT Southern Health & Social Care Trust
WHSCT Western Health & Social Care Trust
MDT Multidisciplinary Team
NWW New Ways of Working
RcPsych Royal College of Psychiatrists
CSIP Care Services Improvement Partnership
IEAP Integrated Elective Access Protocol
DLT Discharge Liaison Team
ECR Extra Contractual Referral
PBNI Probation Board Northern Ireland
LD Learning Disability
PQC Promoting Quality Care
PSNI Police Service Northern Ireland
IPDE International Personality Disorder Examination
PCLR Psychopathy Check List-Revised
STAR Salford Tool for Assessment of Risk
HCR20 Historical Clinical Risk 20
RSVP Risk of Sexual Violence Protocol
ARMADILO Assessment of Risk and manageability of Intellectually Disabled individuals who Offend
RAMAS Risk Assessment Management and Audit Systems
CBT Cognitive Behaviour Therapy
DRAMS Dynamic Risk Assessment & Management System
START Short Term Assessment of Risk
Page 20 of 28
Inter Ministerial Group
Minister
DHSSPS
Project Board
Senior Representatives of Stakeholders
Mental Health and Learning Disability Taskforce –
Project Team HSCB/PHA
Taskforce Sub Groups – Representatives of Service Users, Carers, Voluntary Organisations, Trusts, other Statutory Bodies, Board
and Agency
APPENDIX 1 - Mental Health/Learning Disability Bamford Taskforce – Project Structure
Adult Mental
Health
Chair:
Seamus
Logan
Protect Life and
Mental Health
Promotion
Chair: Madeline
Heaney
Specialist Support
Services
(including
Forensic, Low
Secure, Personality
Disorder and
Prison Mental
Health)
Chair: Molly
Kane
Autistic
Spectrum
Disorder
Chair:
Stephen
Bergin
Eating
Disorders
Chair:
Stephen
Bergin
Learning
Disability
Chair:
Aidan
Murray
CAMHS
Chair:
Rodney
Morton
New Strategic
Direction for
Drugs and
Alcohol
Joint Chairs:
Stephen
Bergin/Cathy
Mullan
Contact Details of Sub Group
Chairs:
Seamus.Logan@hscni.net
Stephen.Bergin@hscni.net
Molly.Kane@hscni.net
Aidan.Murray@hscni.net
Rodney.Morton@hscni.net
Madeline.Heaney@hscni.net
Cathy.Mullan@hscni.net
Page 21 of 28
Appendix 2 – Literature Review
• The Reed Principles (1991) as aspired to in the Bamford Review (2005),
stated that patients, including Mentally Disordered Offenders should be
cared for ‘as far as possible in the community rather than institutional
settings’.
• The Bamford Forensic Services Report (2006)
http://www.dhsspsni.gov.uk/forensic_services_report.pdf makes a total
of 169 recommendations relating to the care and treatment of Mentally
Disordered Offenders with several recommendations to the on-going
development and operational capacity of community forensic services.
• Bamford Action Plan (2009)
http://www.dhsspsni.gov.uk/bamford_action_plan_2009-2011.pdf
recommends the establishment of a N. Ireland Forensic Mental health
and Learning Disability Steering Group, to ensure better joined up
services for people who need forensic services.
• Priorities for Action (2010/11)
http://www.dhsspsni.gov.uk/microsoft_word_-
_priorities_for_action_2010-11.pdf require Commissioners and Trusts to
maintain the staged developments of specialist services, including
forensic mental health and learning disability services.
• Health and Social Care (Reform) (N. Ireland) Act 2009
http://www.legislation.gov.uk/ukpga/2009/21, Sections 19 and 20 place
a statutory duty on HSC organisations to ensure that there are structures
in place where individuals and local communities are actively engaged in
their own health and wellbeing and in improving and shaping local
services, thus ensuring services are person centred, responsive and
meet the individuals assessed needs appropriately.
• Not a Marginal Issue, Criminal Justice Inspectorate Report (2010)
http://www.cjini.org/CJNI/files/24/24d6cd45-20bb-4f81-9e34-
81ea59594650.pdf, findings point to the need for a more coordinated
and focused approach to the delivery of mental health services that
concentrates on the need to divert people away from custody where
appropriate and provide the right care in the right setting. Furthermore,
the need to improve the interface between justice and health, whilst
strengthening linkages with care in the community.
• Promoting Quality Care (2010) http://www.dhsspsni.gov.uk/good-
practice-guidance-and-risk-assessment.pdf. Departmental guidelines
describing the principles of best practice in making decisions about
managing risk and potential risks that service users may cause harm to
themselves or others. The broad principles of this guidance are to be
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applied to any individual receiving care and treatment from learning
disability and specialist mental health services, including forensic
services.
Page 23 of 28
Appendix 3
The following excerpts are drawn from the NNW document as indicators of
effective MDT working:
Leadership: should be based primarily on competence rather than profession,
with the focus on the team rather than the individual professions. The teams’
ethos will be of developing the competence of all its members rather than one
or two professions dominating the proceedings, this in turn makes the team
more effective and stronger.
Team working and attitude: The team culture is one where by each individual
takes personal responsibility for the governance of their work in an
atmosphere of openness. Those with the most experience and clinical skills
will deal with people with the most complex needs whilst supporting and
developing the less experienced team members, thus building their
competence, which in turn impacts positively on the overall teams’
capabilities.
User and carer focus: Care is delivered through the sharing of capabilities
within the team and blending them to the needs of the individual service user.
Care is also delivered on a clear service pathway by the most competent
practitioner to provide it, regardless of profession. Users and carers believe
that their individuality is being responded to and therefore can engage more
effectively with the service.
Innovation and efficiency: Services are underpinned by a system of care
coordination, in which interventions are organised and delivered when
required, this leads to more effective and efficient service delivery. This
approach frees up practitioners, allows for even distribution of the workload,
facilitating the timely management of increasing demands that can be placed
on the service.
The intelligent use of information: Service structures and processes facilitate
transparent and open caseload management. Through the processes of
supervision and dynamic team meetings, everybody is challenged to consider
what progress is occurring. Adopting this approach allows team members to
know the bigger picture and see beyond the clinical work they are engaged in.
This in turns creates a service that is dynamic and there is clear evidence of
clinical movement, benefiting not only the team but also service users and
carers.
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The fundamental principle underpinning the decision making processes within
the multi-disciplinary team is the concept of Recovery and Strengths based
practice. This approach recognises that clients often feel powerless and
disenfranchised, that these feelings can interfere with initiation and
maintenance of mental health care, and that the best results come when the
client feels that treatment decisions are made in ways that suit their cultural,
spiritual, and personal ideals. The Recovery approach focuses on wellness and
resilience and encourages clients to participate actively in their care.
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Appendix 4
A number of principles underpin the delivery of an effective and efficient
stepped care model of service delivery:
• Treatment should always have the best chance of delivering positive
outcomes while burdening the patient as little as possible.
• A system of scheduled review is in place that detects and acts on non-
improvement to enable stepping up to more intensive treatments or
stepping down where a less intensive treatment becomes appropriate.
• The establishment of a single point of access in association with robust
screening, triage and assessment function.
• A focus on early intervention and signposting people to the most
appropriate care and services which are provided by the Trust and/or
voluntary/community/independent sector organisations.
The stepped care model creates structures that facilitate a single point of
access to all mental health and learning disability services, offering pre-referral
advice, screening assessment and treatment or onward referral. The model
provides a clear pathway which sets out how people will move through the
service, ensuring they get the most appropriate care by the right part of the
service.
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APPENDIX 5 – Care Pathway Diagram Referral pathway into Community Forensic Teams:
All referral proforma must be completed:
Referral Form Comprehensive Risk Assessment
Case Summary letter
≤ 1 working day
If referral proforma not completed referring agent contacted
and advised of need to forward required info and that referral will be put on hold
until all relevant info received
≤ 7 working days ≤ 1 working day ≤ 1 working day ?? ≤ 15 working days
Referral received by CFT
Initial screening to ensure proper
completion of proforma and
determine urgency
Case discussed at CF MDT meeting
Intervention level agreed and case
allocated to appropriate member of
team.
Following MDT discussion referral
deemed inappropriate and declined.
Written communication to referring agent/Key
worker/GP indicating;
• Referral acceptance
• Forensic lead in case
• First appointment date which will be ≤ 15
working days from CFMDTM
• Intervention level
Written communication to referring
agent outlining reasons for declining
with the offer to discuss and reconsider.
Level 1 & 2
Preliminary summary report forwarded to
referring agent/key worker/GP within 15
working days. To include progress update and
initial formulation.
Level 3 &4
Multi-disciplinary/agency case review
within 3-6 months.
On completion of Level 2 intervention referral
discussed at next CFMDT meeting to determine
next steps
Case closed with full report and formulation sent to
referring agent/key worker/GP, with offer to meet
and discuss findings.
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Appendix 6 – Objectives of Forensic Mental Health and Learning Disability
Services
• To develop a service which is safe, secure and supportive, with skilled,
confident staff who aim to manage risk effectively, within a framework
of organisational managerial support.
• To promote patient, carer and whole family approaches in the
development of treatment plans, through choice, negotiation and
person centred approaches.
• To integrate closely with existing services.
• To facilitate the integration and maintenance of the individual into
society, as far as is possible.
• To work in partnership with other relevant agencies for the benefit of
patients, facilitating, establishing and maintaining a team knowledgeable
of local, statutory and independent services.
• To monitor the changing needs of the forensic caseload (by developing a
case register and routinely assessing need) and bring unmet need to the
attention of the mental health and learning disability senior
management team and commissioners.
• To regularly evaluate service and facilitate ongoing improvements - from
patient, carer, referrer and staff perspectives.
• To promote awareness of forensic mental health and learning disability
issues, including the valuable work of other agencies involved in the
delivery of services to this complex population.
• To provide a training resource for other professionals.
• To contribute to the Bamford Action Plan for Forensic services.
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Appendix 7 – Forensic Team composition (as of April 2011)
Team composition
Trust Post WTE
Belfast Trust* and
South Eastern Trust
Band 7 Nurse Band 7 Social Worker Band 8A Social Work Locality Manager Band 6 OT (not funded) Consultant Consultant Psychotherapist Band 8c Psychologist Band 4 Admin Band 3 Admin Band 2 Admin (not funded)
3.0 3.0 1.0 1.0 1.0 0.25 0.5 1.0 1.0 1.0
Southern Trust Band 7 Practitioners Band 6 (vacant) Band 3 Admin Forensic Consultant Forensic Psychologist
3.0 2.0 1.0 0.5 0.8
Western Trust Consultant Junior Doctor Band 8A Band 7 Practitioners Band 6 Band 4 Band 3
0.5 0.5 1.5 1.0 4.0 1.0 1.50
Northern Trust Nurse Practitioners OT Forensic Team Leader Clinical Psychologist Forensic Psychiatrist Personal Secretary
4.0 (2 vacant) 1.0 1.0 0.75 0.5 1.0
Forensic Learning Disability Team Composition
Trust Post WTE
Belfast Trust Band 8B 1.0
Southern Trust Forensic Psychiatrist Forensic Psychologist Band 7 Practitioners
0.2 0.2 2.0
Western Trust No Forensic Learning Disability Service
Northern Trust Learning Disability Nurse Practitioner Learning Disability Social Work Practitioner
1.0 1.0
South Eastern Trust No Forensic Learning Disability Service
* Belfast Trust was commissioned by the legacy Eastern Health & Social Services Board to provide Community Forensic Services to both Belfast and South Eastern Trust areas.
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